Fatal coronary vasospasm following oral triptan intake

Abstract

Triptans, commonly used for migraine treatment, induce vasoconstriction by activating 5HT1B/1D and 5HT1F receptors. Although several cases of coronary vasospasm associated with sumatriptan have been reported, few describe life-threatening arrhythmias and cardiac arrest. We present a case of fatal coronary vasospasm caused by triptan use in a young patient with minimal cardiovascular risk. A 30-year-old man with morbid obesity was admitted for unstable angina. He reported chest pain episodes starting one month earlier, coinciding with the initiation of oral sumatriptan for migraines. On the second day of hospitalization, he took 100 mg of sumatriptan. Ninety minutes later, he developed recurrent chest pain that progressed to cardiac arrest caused by a ventricular arrhythmia storm. Left anterior descending artery vasospasm with ST-segment elevation myocardial infarction was identified, and intracoronary nitrate and adenosine relieved the spasm. However, resuscitation was ineffective due to morbid obesity, leaving the patient in profound cardiogenic shock, followed by distributive shock from prolonged low-flow time. Despite maximal hemodynamic support, he succumbed to multiorgan failure. This case highlights the potentially fatal cardiovascular risk of triptans, even in low-risk patients, and underscores the need to discontinue triptans at the first sign of chest pain.

Learning objectives: Coronary vasospasm, a rare but severe complication of triptans, can lead to life-threatening arrhythmias and cardiac arrest, even in patients with low cardiovascular risk. Diagnosing vasospasm is challenging, as angiograms may appear normal during symptom-free intervals. This case highlights the need for heightened clinical suspicion when chest pain follows triptan use, emphasizing the importance of recognizing this risk to ensure prompt management and avoid fatal outcomes.

Keywords: Acute coronary syndrome; Coronary vasospasm; Triptans; Ventricular fibrillation.

Fig. 1

Electrocardiogram of the patient at admission to the emergency department during pain-free interval (A) and the following day during chest pain (B).

Fig. 2

Coronary angiograms showing the vasospasm of distal left anterior descending artery (A) and its progressive improvement after intracoronary administration of nitrates and adenosine (B and C).